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Dr. Gawande Answers Questions About ‘The Itch’

If you haven’t read the recent New Yorker article, “The Itch,” by Dr. Atul Gawande, then you should stop reading this post now and go read it.

But if you did read “The Itch,” then you, like me, are probably still thinking about it. “The Itch” tells the story of a chronic itch experienced by a patient called M. and details her subsequent suffering. The article also explores how the brain interprets various stimuli and includes fascinating insights into the phantom limb sensations of amputees. But mostly, it’s about itching.

Many people who read the article, however, were disappointed by the end, which left them hanging about what happened to patient M.’s itch. Other readers on this blog have expressed disbelief about some of the more shocking aspects of the story.

I e-mailed Dr. Gawande, who kindly agreed to answer a few of your questions about “The Itch.”

Q. A reader on the blog states that it would be impossible for M. to scratch through her skull with her fingernail. What is your response to that concern?

A. As for being able to scratch through one’s skull — it’s the same thing the doctors thought when they saw her. And they therefore kept surmising that she had used some kind of metal implement to scratch. But gradually what they figured out was that the open skin wound had allowed bacteria in. This led to osteomyelitis — infection of the skull — and that softened the skull to the point of allowing her to gradually scratch through.

Q. One part of the article suggests that M. was “next to” a male patient who also had an itch and eventually died after scratching through to his carotid artery. But how do you explain that, since hospital wards wouldn’t allow a male and female patient to share a room?

A. By “the man next to me” she meant in the room next to her. Definitely not in the same room.

Q. The story ends with speculation that a dual-mirror therapy might help patient M. Why didn’t you tell us what happened and whether the therapy worked for her?

A. I haven’t been satisfied that the illusion will work properly in a double mirror. There’s actually a company that makes Positive Mirrors, which show you as you are actually seen. They’re sending the mirror to me and I’m going to pass it along to M.

I have described the approach to M., and she certainly could have tried Ramachandran’s suggestion on her own. I’m not sure why she hasn’t yet. One possibility is you have to go out and buy two mirrors. I am reluctant to cross the line and treat these people as if I were their doctor. It’s an awkwardnesses of my role as a doctor who also does journalism. I usually make a bright line with people so they understand that I’m their journalist, not their doctor, when I’m meeting folks like these. Plus, I’m a general surgeon, not a neurologist.

Nonetheless, we got chatting. I mentioned these cool studies I’d been thinking about for the article, and it seemed like trying the mirror treatment was both harmless and worth a try. But the minute I am actually devising new treatments for people, it feels like it’s crossing a line. So I’m happy to bring them ideas; I’ve alerted their neurologists to my thinking (especially when it helped H. so much); and I’ve encouraged them to discuss the ideas with their neurologists. But I’ve also made it clear I can’t be their doctor.

This article was absolutely fascinating. It reminds one that medical practice today seems to be an incongruous mixture cutting edge molecular science, pragmatic remedies, and harmless folklore. Why do we itch? Why do we sleep? Why do we dream? Advances in medical treatment are carried out not only by the lab-coated scientists doing the basic research but also by practitioners with the imagination to think outside the box and willingness to subject their results to scientific testing. It’s really nice to read articles like this that are far from the news-you-can-use variety telling you about some study that has shown that eating [fill in the blank] prevents/causes [fill in the blank].

Thanks for this. However, I would have loved more questions particularly about the science of perception that he surveys in the essay. I thought that was fascinating as he investigated the mysterious source of itching. I have been so impressed by Dr. Gawande’s excellent essays that as soon as I finished reading “The Itch” I wrote an entry on him on my blog “moments of tranquility” to pay him a little homage.

Reading Dr. Gawande’s article about M has left me thinking about it for days. I have suffered considerable itching. At one point both my outer arms were covered with scabs and scratches. My sheets would be bloody when I woke up each morning. I finally went to a dermatologist in Seattle who treated me with topical medicines which has to be bandaged for about a week. The severe itching got better but it returns from time to time. It starts with an itch, no marks, just an itch someplace on my arm. Now I use ice, hydrocortisone and anti-histimines to stop it in the tracks – if possible. It is hard to believe it can get so bad and for so long. My heart goes out to M and the others. Every mosquito bite sends me into a panic but it’s been okay for many years now. However it is no wonder I can’t stop thinking about M and her dreadful itch.

The article by Dr. Gawande is a wonderful introduction to how the mind contructs “reality.” The social psychologists have been looking into this for quite some time. David Gilbert from Harvard has written a fascinating book called “Stumbling on Happiness” which, with great wit, and lots of research in plain English details how we construct the future based on the present and our faulty, constructed memories of the past. It is well worth reading.

I didn’t read the article…a friend began to tell me about it and a few words into her description I felt faint and had to sit down. I’m usually pretty unmoved by graphic medical things but for some reason this one just got me. Yikes. You think you’ve heard or seen everything and then this story comes up.

I have been talking about this article all week. I nearly fell out of my chair when I read it, more from amazement than revulsion. I have worked in public hospitals, and thought I had heard some wild stories, but M.’s case is amazing. I too was curious about what might happen if she tried the mirror therapy. Dr. Gawande’s articles are some of my favorites in the New Yorker. Thanks for the follow up.

During a bout with severe itching due to my liver disease, now improved) I became very interested in chronic itch. I am a physician who treats patients with chronic spine pain, and after reading the scientific “itch literature,” I was struck by the many things chronic itch and chronic pain have in common. Both can cause severe distress, impairment, disability, and depression. Both can seem mysterious and be hard to treat. Many patients with pain or itch who prove refractory to usual treatment are labeled as having a “psycho-somatic problem,” rather than a difficult to understand neurophysiological illness. However, it is important to know that the patients described by Dr. Gawande are at the very extreme and most dramatic end of the spectrum of patients with chronic itch. It is importnat to recognize that in many or most instances, physicians who specialize in chronic itch have learned how to effectively treat many if not most patients with medications, topical therapies, and other means. The International Forum for the Study of Itch has an excellent patient-friendly web site as well.

The itching story recalls the epistemological debate over sense data theory and how are knowledge of the world is formed. It seems to support more nuanced theories (Quine e.g. ) of how thought and perhaps feelings exist side by side and how it is necessary to readjust the entire lattice of belief when a fundamental belief – such as I have a right hand – conflicts with reality. A really interesting article.

I read Dr. Gawande’s article in the New Yorker with great interest since I get itches on my legs which are very intense (keeping me up at night), and haven’t responded to any treatment so far. I scratch by rubbing my fingers over the itch. This is as effective as clawing at it with my fingernails, but does not destroy my skin. I have an appointment with a neurologist, but I have few expectations of much help in light of Dr. Gawande’s article.

In Samuel R. Delany’s novel Nova, he postulates the concept of ‘neurocongruence’, which is central to his plot. According to him, there is a nerve plexus in the brain that looks like a plan view of the human body.
If something is missing from this plexus, say an arm, then even if a physical arm is replaced with a graft or prosthetic, the body will not be able to use it.
I wonder if that might work the other way, in which phantom itch or limb pain results from the missing
physical member, but the corresponding parts of the nerve plexus remain active

I had Shingles in my eye, forehead and scalp 10 years ago.
I am almost free from pain, but the itchiness
can sometimes reach a 10 in intensity.

I take Lyrica and topamax.
When pain or itchiness breaks through, I use Zonalon Cream (doxepin HCl)on my eyebrow and forehead up to my hairline. Not in my hair,
even though the itch, which causes me to act suddenly like a wild woman, is in my scalp.
The Zonalon Cream takes away the pain or itch imediately.

People who suffer from itching might want to try taking a tablespoon of cod liver oil every day. I recommend Carlson’s Norwegian because the manufacturer takes care to filter out mercury and other impurities and because it’s lemon flavored. I have had such severe itching that a simple scratch could draw blood. It wasn’t unusual for me to awaken with blood spots on my sheets. Thanks to cod liver oil, which is abundant in Omega 3 fatty acids, I no longer have that problem.

I have a chronic cough which comes on when I feel an itch sensation in my bronchi. I went through a series of tests at Mayo Clinic and was told in the end that some people are more itchy than others. An allergist in Oklahoma City told me not to cough as coughing itself brings on coughing. Has anybody had a similar problem, and found any relief?

This article causes me to wonder if the problem resides in my brain, not my chest.
Elaine K

I suffer from chronic itch on my bum and have been to countless doctors prescribing everything from ‘well stop scratching it’ to topical creams often carrying grave warnings. When I could afford regular acupuncture that eventually gave me relief. Otherwise I suffer everyday, keep my nails short, wrap my hands at night when it is particularly bad, and beg myself to stop scratching! I have also thought of hypnosis. Would that work? It is true, that pain suffered through scratching your skin till it bleeds is bizarrely better then the piercing intensity of the itch. I appreciated this article for making me feel less alone.

Great article and I totally relate to it. During graduate school, I was under tremendous stress and developed an itchy scalp. It progressed from an occasional itch, to a full blown condition that resulted in my digging into my scalp with fingernails causing bleeding and infecting the areas. I found in some sick way that it actually relieved my mental stress to do this. It lasted for approximately two years and disappeared shortly after graduation. I was well aware while I was doing it that it was getting worse and was, believe or not, reluctant to stop it. I never mentioned it to my doctor. I liken it to the relief one feels when, while suffering from acute poison ivy or sumac, you take a hot shower or bath and scratch the area with vigor. What a relief! Another thought- some years ago the Japanese identified a similar problem among youth they never did resolve. Hmmm?